"AN EQUAL OPPORTUNITY EMPLOYER - MFDV"
TO APPLICANT:You may exclude all information you feel indicative of age, sex, race,religion, color, national origin or physical disability. / Date:
Position Desired:
PERSONAL DATA / NAME: / Last: / First: / MI / S.S. #:
ADDRESS: / Street: / City: / State: / Zip: / Other Address:
TELEPHONE NUMBERS: / Day: / Evening: / (If no phone, how can you be reached?)
U.S Military Service: Yes No If yes give:
Branch: Service Dates:
EMPLOYMENT INFORMATION / Position for which you are applying: / Salary Expectation: / Date Available:
Expand on the type of work you prefer: / Referral Source:
Ad: Walk-in: Agency: Friend: Relative: Other:
Have you ever been employed with us before?
Yes No If yes, when?
What location & company? / Have you filed an application here before?
Yes No If yes, when?
What location & company? / Would you work other than full-time?
Yes No
Part-time: Temporary:
If clerical applicant:
Can you type? Yes No WPM
What office machines do you operate? / Have you been convicted of federal, state, county or municipal law, regulation or ordinance including court martials while in service but excluding misdemeanors, traffic violations and similar offenses?
Yes No If yes, describe the facts, circumstances, & rehabilitation: / Are you employed now?
Yes No
If yes, may we contact your present employer?
Yes No
GENERAL SKILLS & EDUCATIONAL INFORMATION / HIGH SCHOOL
School name & address:
Years completed: 9 10 11 12
Average grade:
Diploma / Degree (if yes, what degree): Yes No
Major / Minor: / COLLEGE / UNIVERSITY
School name & address:
Years completed: 1 2 3 4 5 6
Average grade:
Diploma / Degree (if yes, what degree): Yes No
Major / Minor:
Describe course of study and list any technical or specialized skills, training or licenses held:
Scholastic awards, honors, offices held, honorary academic societies, organizations, etc.:
Technical articles published, patents, inventions, etc.:
Scientific or professional organizations of which you are a member:
Foreign languages and degree of skill:
Other information: community activities, hobbies, interests. etc.:
READ / TO APPLICANT: As a government contractor we are subject to (1) Section 402 of Vietnam Era Veterans Readjustment Assistance Act of 1974 which requires us to take affirmative action to employ and advance in employment qualified disabled veterans and veterans of the Vietnam Era, and (2) Section 503 of the Rehabilitation Act of 1973 (including the ADA of 1990) which requires us to take affirmative action to employ and advance employment of qualified handicapped individuals. If you have a situation which is covered underneath one of these Affirmative Action programs and would like to be considered under the program, please tell us. This information is voluntary and refusal to provide it will not affect consideration. Information obtained concerning individuals shall be kept confidential, except that, if employed, (i) supervisors and managers may be informed regarding restrictions on the work or / duties of individuals and regarding necessary accommodations, (ii) first aid and safety personnel may be informed, when and to the extent appropriate, if the condition might require emergency treatment, and (iii) government officials investigating compliance with the Act shall be informed. In order to assure proper placement of all employees, we do request that you answer the following questions: If you have a situation which might affect your performance or create hazard to yourself or others in connection with the job for which you are applying, please state the following: (1) any special methods, skills and procedures which qualify you for positions that you might not otherwise be able to do because of your situation, and (2) the accommodations that we would make which would enable you to perform the job properly and safely, including special equipment, changes in the physical layout of the job, elimination of certain duties relating to the job or other accommodations.
EMPLOYMENT EXPERIENCE: List jobs in order held, present or most recent first. A copy of resume may be attached to expand work experience. Give name and address ofemployer, dates to/from, position held, ending and starting salary and reason for leaving. Include periods of unemployment for chronological purposes.
Employer: / Date / Describe position:Month & Year
Street / From / To
City and State: / Rate of Pay / Reason for leaving (if you had disciplinary problems, please describe the facts and circumstances)
Starting / Ending
Supervisor: / $ / $
Employer: / Date / Describe position:
Month & Year
Street / From / To
City and State: / Rate of Pay / Reason for leaving (if you had disciplinary problems, please describe the facts and circumstances)
Starting / Ending
Supervisor: / $ / $
Employer: / Date / Describe position:
Month & Year
Street / From / To
City and State: / Rate of Pay / Reason for leaving (if you had disciplinary problems, please describe the facts and circumstances)
Starting / Ending
Supervisor: / $ / $
Employer: / Date / Describe position:
Month & Year
Street / From / To
City and State: / Rate of Pay / Reason for leaving (if you had disciplinary problems, please describe the facts and circumstances)
Starting / Ending
Supervisor: / $ / $
oTHER INFORMATION: Any additional comments pertinent to your qualifications not covered by this application may be made on a separate sheet as necessary.
References (do not give relatives or previous employer):
Full Name:
1.
2.
3. / Address & Phone #: / Position or Occupation / Years Known
APPLICANT UNDERSTANDING AND AGREEMENT
Thank you for your display of interest in our Company by completing this application for employment. Be assured that our management decision on employment is based on a conscientious matching ofjob requirements with applicant skills and qualifications without regard to race, color, creed, religion, sex, age, national origin, ancestry, physical disability, military disability or veteran status. The intentof our employment effort is to derive positive benefit through the best utilization and developmentof human resources.
Please read the following carefully and sign only after you have completed the application.
1. The information I have provided is correct and accurate to the best of my knowledge and I permit verification.
2. I authorize and hereby release from any and all liability and responsibility all persons, companies or corporations supplying verification or relevant information or opinions to this application that may be required to arrive at an employment decision, and to Layne Christensen Company in obtaining the same.
3. Before employment, I understand that I will be required to sign the Employment Certification and Consent Agreement section (see pages 3 and 4). / 4. I fully understand and agree that, during my employment:
A. Any unintentional or inadvertent misrepresentation or deliberate omission of a material fact in this application can justify refusal of employment, or if employed, be cause for immediate dismissal.
B. I will submit to a physical examination and I authorize any physician who has ever examined or treated me to give the Company a complete record and report and further agree to take any physical examinations requested by the company.
C. I will use such personal protective equipment practices and devices as may be directed by the Company to comply with safety rules and requirements.
D. Any employment I might be offered is of an indefinite duration, and that either the Company or I can terminate that employment at any time with or without notice for any reason.
Signature of Applicant
EMPLOYEE'S CERTIFICATION AND CONSENT AGREEMENT
My signature below signifies my agreement to the following:
RECOGNITION OF AT WILL STATUS
I understand that I am an employee at will, that my employment is of an indefinite duration and that either I or the Company can terminate the relationship at any time without need of formal notice or reason by either party. No agreement to the contrary will be recognized without written approval of the President. I further recognize that the terms and conditions of my employment may be changed by the Company at any time, with or without notice.
AFFIDAVIT
I do not advocate, nor am I a member of any organization that advocates, the overthrow of the Government of the United States by force or violence or other unconstitutional means, or seeking by force or violence to deny other persons their rights under the Constitution of the United States. I do further affirm I will not so advocate nor will I become a member of such organization during the period that I am an employee. To do so may be considered sufficient cause for immediate discharge.
EMPLOYEE CONSENT
I consent to having my urine tested for the presence of controlled substances in my body as a part of the pre-employment physical examination if required or at any time during employment at the sole request of the Company. I authorize any duly licensed medical and/or nursing personnel acting on behalf of Layne to draw blood specimens from my body for the purpose of determining serum drug and/or alcohol and/or controlled substance levels which may exist in my blood. I understand that if the Company has a reasonable suspicion that I am impaired due to drug and/or alcohol use it may request me to submit to the tests described above. My refusal to submit to such tests will subject me to discipline, up to and including suspension and discharge.
I understand that the results of these diagnostic examinations may be retained by the Company as exclusive Company property and will be reported to the local management, will be kept absolutely confidential and will be used solely in determining my eligibility for employment or continued employment as an employee. Further, I have read and understand the provisions of the Layne Christensen Company Drug Free Workplace Policy and agree with the policy therein set forth.
Signature: / Date:Witnessed: / Date:
THIS AGREEMENT, made and entered into as of the date set forth below by and between Layne Christensen Company, acting for itself and all subsidiary, affiliated and associated companies which it now has or may hereafter have, and the undersigned EMPLOYEE (the ''Employee");
WITNESSETH:
WHEREAS, the Company has developed in its business and uses commercially valuable technical and non-technical information and, in order to guard the Company's legitimate interests, it is necessary for the Company to protect certain of the information either by patents or by holding it secret or confidential; and
WHEREAS, Employee may become acquainted with the aforesaid information and may contribute thereto, either through inventions, discoveries, improvements or otherwise;
NOW, THEREFORE, in consideration of employment or continued employment of Employee by the Company, the parties hereto hereby agree as follows:
1. Definitions. As used herein the following terms have the following meanings:
A. The "Company" shall mean Layne Christensen Company, and any of its existing or future subsidiaries, associated companies and affiliates and any joint venture to which it is or may become a party.
B. "Confidential Information" shall mean information relating or pertaining to past, present or prospective business secrets, methods or policies, earnings, finances, security holders, lenders, key employees, nature of services performed by the Company's sales and production personnel, quality control procedures or standards, procedures and methods of cost control, research and development, engineering data and design methods and procedures of production and fabrication, method and procedures involving construction, or installation of the Company's products and components, information relating to arrangements with suppliers, the identity and requirements of arrangements with customers, and the type, volume and profitability of work for such customers, drawings, records, reports, documents, manuals, techniques, procedures, formulas, ratings, design information, data, statistics, trade secrets and all other information of any kind or character relating to the Company, whether or not reduced to writing, which the Company considers confidential and which is not generally available to the public.
C. "Inventions" shall mean inventions, devices, discoveries, improvements, formulas and ideas (whether patentable or not) that are useful in or related to the actual or anticipated business or activities of the Company, or directly or indirectly related to the Company's actual or anticipated research and development, or suggested by or result from any task assigned to employee, knowledge gained by Employee during employment, or work performed by Employee for or on behalf of the Company.
2. Obligation of Confidence.
A. Employee shall, either during the term of his employment with the Company or at any time subsequent to the termination of such employment:
(i) Never communicate, publish or otherwise disclose any Confidential Information to any party, other than to other employees of the Company authorized and required to receive such information in the performance of their duties for the Company or except as otherwise specified here; and
(ii) Never use any Confidential Information, either for the benefit of himself or for the benefit of any person, firm, association, corporation orentityother than the Company.
B. Throughout the course of his employment by the Company, Employee shall:
(i) Use his best efforts at all times tosafeguard any Confidential Informationmade available to him from falling into the hands of any unauthorized person;
(ii) Not permit any Confidential Information which has been reduced to writing to be read, duplicated or extracted except upon authorization of the Company;
(iii) Treat all documents and other materials prepared or developed by him which are Confidential Information as confidential and mark them appropriately;
(iv) As to the Company's employees or any others to whom Employee is required to make disclosures consistent with the Company policies, make such disclosures only in strict compliance with instructions of the Company and require of any person to whom such disclosures are made an obligation of confidence consistent herewith;
(v) Not advise others that Confidential Information is known or used by the Company or others associated with the Company;
(vi) Abide by all other provisions and rules and regulations of the Company; and
(vii) Not disclose to the Company, or induce the Company to use, any Confidential Information or materials belonging to others.
3. Return of Confidential Information. Upon termination of employment, or whenever the Company shall request, Employee shall deliver to the Company all drawings, blueprints, manuals, letters, notebooks, reports and all other materials which are of a secret or confidential nature relating to the Company's business or contain Confidential Information and which are in the possession or under the control of the Employee, whether or not prepared by such Employee.
4. Inventions. Based on knowledge gained or Confidential Information obtained from employer with respect to Inventions made, developed or conceived by
Employee, either alone or jointly with others, in whole orin part, during (a) the period of employment, either when on or off duty, or (b) within one year after termination of any employment, the Employee:
(i) Shall promptly and fully inform in writing the Company of such Inventions;
(ii) Shall assign (and does hereby assign) to the Company, or at the Company's request to any nominee of the Company, all of the Employee's interest in such Inventions, and to applications for patents (whether in the United States or in foreign countries) and any patent granted upon such Inventions, whenever so requested by the Company;
(iii) Shall acknowledge and deliver promptly to the Company or its nominee (without charge to the Company but at the expense of the Company) such written applications, assignments and other instruments and to do such other acts as may be deemed necessary or appropriate by the Company to obtain and maintain in effect domestic or foreign letters patent or to otherwise protect the Company's rights in the Inventions and to vest the entire right and title thereto in the Company; and
(iv) Does hereby irrevocable appoint the President of the Company his attorney in fact with authority to execute for Employee and on his behalf any and all assignments, patent applications, releases or other papers required to be executed by Employee pursuant to the foregoing.
The Company shall be under no obligation to protect by patent any such Invention, except at its own discretion and to such extent as the Company deems desirable.
Except as listed on the back of, or attached to, this Agreement, Employee will not assert any rights under any Inventions as having been made or acquired by Employee prior to employment by the Company.
5. All Work Product and Property of the Company. All records and documents covering any Inventions, formulas, processes and techniques, and all drawings, reports, manuals, and other information, relating to any activity of the Company or within or pertaining to the existing or contemplated scope of the Company's business or connected in any way with the work or tests carried out by the Company, which has been conceived, prepared or developed by the Employee, either alone or with others, during his employment by the Company, while on or off duty (herein called 'Work Product') shall be the sole property of the Company, and if so considered by the Company shall be treated as Confidential Information of the Company under the terms of this Agreement. During or after the term of Employee's employment by the Company, Employee will not disclose or discuss with anyone not in the employ of the Company any such Company Work Product without written authorization of the Company, nor will he disclose to others without such written authorization any knowledge which he may have concerning any Invention or Company Work Product.
6. Other Obligations Continue. This Agreement is in addition to, and shall not be exclusive of, any and all other obligations or duties of the Employee, whether expressed or implied in fact or in law with respect to the subject matter of this Agreement; provided, however, this Agreement shall supersede any and all agreements, understandings, statements, inducements or representations which have been made by the parties hereto to the extent any of them relates to the subject matter hereof. Nothing herein contained shall be construed as limiting the Company's right to terminate Employee's employment or other association with the Company.
7. Amendment; Binding Effect. No modifications of this Agreement shall be binding on either party unless expressed in writing, signed by the parties hereto and attached to and made a part of this Agreement. This Agreement shall be binding on the parties hereto and their heirs, executors, representatives, successors and assigns. This Agreement shall be a construed, interpreted and governed by Layne Christensen Company.